Parental supervision and sexual behavior among Brazilian adolescents

ABSTRACT Objective: to evaluate the association between parental supervision and sexual behaviors among Brazilian adolescents. Methods: Cross-sectional study with data from 102,072 adolescents who responded to the National Adolescent School-based Health Survey. We estimated the prevalence of sexual behaviors (initiation, use of condoms, contraception, and number of partners). Parental supervision was evaluated using a score considering five indicators. We calculated prevalence ratios (PR) adjusted by age and sex in order to estimate the association between parental supervision score and sexual behaviors of adolescents. Results: Prevalence of risky sexual behavior for adolescents with minimum and maximum parental supervision were: sexual initiation (min.: 58.0%; max.: 20.1%), condom use in the last sexual intercourse (min.: 50.9%; max.: 80.2%), use of contraceptives (min.: 40.8; max.: 49.1%), and mean number of partners (min.: 3.25; max.: 2.88). Parental supervision was greater among girls. Those with higher supervision scores had higher prevalence of condom use in the first and last sexual intercourse and of contraceptive methods, and a smaller mean number of partners, even after adjustments for sex and age. Conclusion: The greater the parental supervision, the better the sexual behavior for both sexes, although supervision seems to occur differently between girls and boys. These findings point to the role of the family in providing adolescents with monitoring, along with dialogue and affection, conditions that encourage healthy and risk-free sexual behavior.


INTRODUCTION
Adolescence is marked by bodily, cognitive, emotional and social transformations that motivate changes in behavior patterns and demand greater family attention 1,2 . The possibilities of learning, discoveries and experiments in this age group are known to lead to situations of risk and vulnerability, especially when related to sexuality 3 . Unsafe sexual practices occur mainly due to taboos in the discovery and exercise of sexuality, lack of information and lack of communication with family members 4 .
With regard to family, parental supervision-a type of indirect monitoring of the behavior of adolescents 5 that includes the application of rules and parental knowledge about the location and activities of their children, as well as dialogue, affection, among other factors-, can contribute to modify the sexual behavior of adolescents 2,6 . Previous studies have shown that higher levels of parental monitoring are related to a greater probability of delaying sexual initiation 6 and of using condoms and other contraceptive methods 2,7,8 , contributing to the adoption of healthy sexual practices and reproductive health by adolescents. The protective effect of parental supervision on other health outcomes was also seen 2,6,7,9 . International, 2,6,10 national 11,12,13 , regional 1,4,14,15 and local studies, such as in a rural population 16 , have increasingly investigated the sexual behavior of adolescents, including their relationship with parental supervision. However, studies that consider gender differences are less frequent and address few parental supervision indicators 8 , generally related to knowledge about where the teenager is when not at school, which refers to supervision regarding limits and responsibilities. However, issues that refer to dialogue and affection should also be considered 10 . A review study showed differences in supervision depending on gender, with boys receiving more supervision related to risk sexual behaviors while girls receiving more emotional support 10 .
In this sense, this study aimed to evaluate the association between parental supervision and sexual behaviors adopted by Brazilian adolescents of both sexes. It is hypothesized that adolescents with greater parental supervision present lower-risk sexual behaviors.

METHODS
This is a cross-sectional study that analyzed data from Sample 1 of the National Adolescent School-based Health Survey (PeNSE) carried out in 2015, comprising 102,072 adolescents enrolled in and regularly attending public and private schools located in urban and rural areas throughout the national territory in 2015 17 . The survey was carried out by the Ministry of Health (MS) in partnership with the Brazilian Institute of Geography and Statistics (IBGE) and the Ministry of Education (MEC).

Sample design and data collection
Sample 1 of PeNSE 2015 was planned to estimate population parameters in Brazil's Major Regions, Federative Units and municipalities of capitals 17 . For the sampling plan, 53 geographic strata were defined. Each of the 26 state capitals, plus the Federal District, was defined as a geographic stratum, and the other municipalities were grouped into another 26 strata representing each Brazilian state, excluding the capitals 17 . In the 53 strata formed, a sample of schools was selected based on data from the 2013 School Census 17 . To ensure the presence of public (federal, state or municipal) and private schools in an approximate proportion to their existence in the selected register, allocation strata were formed by crossing geographic strata with the network of schools (public or private) and their size, measured by the number of 9th grade classes 17 .
In each school in the sample, the 9th grade classes were selected by lot, and the respective students present on the day of data collection were invited to respond to the research questionnaire using a smartphone. The questionnaire was divided into thematic modules addressing various risk and protective factors, including questions on parental supervision received and on sexual and reproductive health 17 . Further information on the PeNSE sampling plan and data collection methodology can be found at: https://www.ibge.gov.br/estatisticas/sociais/educacao/9134-pesquisa-nacional-de-saude-do-school.html?=&t=what-is

Variables
Parental supervision was the variable of interest in this study. The five questions used to proxy parental supervision are shown in Chart 1. In addition to assessing each variable, the responses of the five variables were added up, generating a score that ranged from 0 to 5. Thus, adolescents whose score was equal to 0 ("yes" for the variable that analyzes missing classes without parental permission and "no" for the other variables) were considered as little or no parental supervision, and those whose score was 5 ("no" for the variable that analyzes missing classes without parental permission and "yes" for the other variables) were classified as "under intense supervision".
Sexual behavior among adolescents was assessed using the following variables: sexual intercourse at least once in life (initiation); use of condom in first sexual intercourse, use of condom in the last sexual intercourse, use of a method to avoid pregnancy in the last intercourse and number of sexual partners in life.

Data analysis
The prevalence of sexual behavior indicators among Brazilian adolescents was estimated according to parental supervision received. Then, the prevalence of parental su-https://doi.org/10.1590/1980-549720230013.supl.1 pervision variables according to adolescents' gender was estimated. The average number of sexual partners reported by adolescents was also calculated, according to parental supervision, for both genders. Statistical differences were measured using Pearson's χ2 test, with a significance level of 5%, and 95% confidence intervals (95%CI).
Finally, crude and age-adjusted prevalence ratios (PR) of adolescents' sexual behaviors were estimated according to parental supervision scores using Poisson regression, considering the magnitude of the prevalence of sexual behaviors 18 . For the variable number of sexual partners, crude and adjusted linear regressions were performed to estimate differences in means. For all analyses, respective 95%CI were estimated.
Adolescents who stated that they had not initiated their sexual lives (n=72,989) were excluded from the analysis of other variables related to sexual behavior.
The "survey" module in the Stata 14 software was used for statistical analysis considering the complex sampling design (stratum, cluster and individual weight) to obtain population estimates.

Ethical Considerations
Participation in the study was voluntary, and students had the option of not responding. No information that could identify the student and the school was collected.  In 2015, 27.5% of Brazilian adolescents enrolled in the 9th grade of elementary schools declared having had sexual initiation. Of these, 61.2% reported using a condom in the first intercourse and 68.6% in the last sexual intercourse, 44.0% reported using contraceptive methods, and the average number of partners reported was 2.8. Among males, higher rates of sexual initiation, non-use of condoms or contraceptive methods and a greater number of sexual partners were observed ( Table 1).

Females
As for parental supervision, the proportion of young people who reported missing classes without permission was higher among males (8.4%). Among males, there was also a higher proportion of parents who were not aware of their children's free-time activities (37.3%). A higher proportion of parents did not check homework (70.1%), did not understand concerns (58.9%) and were not frequently present at meals (29.2%) among female adolescents in comparison with male adolescents (66.1, 53.4 and 22.5%, respectively). When evaluating the parental supervision score, there was a higher prevalence of maximum supervision (score 5) among males (15.8%) ( Table 2).
The greater the parental supervision, the lower the prevalence of sexual initiation and the greater the prevalence of protective sexual behaviors. Of the adolescents with the lowest supervision score, 58% had had sexual initiation, against 20.1% of those with greater parental supervision. Adolescents under high supervision (score 5) used condoms more frequently in the very first (71.1%) and last sexual intercourse (80.2%), while adolescents who had minimal supervision had a prevalence of 49.8 and 50.9%, respectively. With regard to the use of contraceptive methods, the prevalence is also higher when under strict supervision (49.1 against 40.8% of adolescents under low supervision). The number of sexual partners was higher among those under low supervision (mean of 3.25 versus 2.88 for those with high supervision) ( Table 3  and Supplementary Table 1). Table 4 and Supplementary Table 2 show the crude and age-adjusted PRs between adolescents' sexual behaviors and the parental supervision score. It was observed that the higher the parental supervision score, the lower the prevalence of sexual initiation (p<0.001), the higher the prevalence of contraceptive methods and condom use in the first (p<0.001) and last sexual intercourse (p< 0.001), and the lower the average number of partners (p<0.05), even after adjustments. Yes -5 or more days a week 1 No -4 or fewer days a week 0

DISCUSSION
The findings of this study showed gender inequality in the way parents supervise their children, since male adolescents are less supervised in activities outside their homes, and female adolescents are less supervised in the home environment. However, a review of the moderating role of gender in the relationship between parenting and adolescent sexual risk behavior suggests that parental monitoring may be more protective for male adolescents with regard to sex- ual risk behavior, while for female adolescents, the emotional connection with their parents may be a more important factor in preventing risky sexual behavior 10 . The difference found in this study in the way parents supervise adolescents according to gender may be influenced by social models for men and women that are still present in society, since, throughout history, women occupied the domestic space and men the public and political spaces 19 . Despite this uneven pattern, the protective effect of parental supervision was similar for both girls and boys (data not shown).
Sexual initiation was more prevalent among male adolescents, and previous studies show that male adolescents indeed initiate sexual life earlier 4,9,20,21 . Gender aspects can also explain this difference in the age of sexual initiation, since male and female roles in traditional social representation guide different expectations, in which men's behaviors are related to masculinity and virility, while, for women, expectations are that they are more dependent, conformist and submissive 22 . Thus, parental monitoring differs according to biological sex 9 .  Our findings show that, among adolescents who have already started their sexual lives, health risk sexual behaviors were less frequent as the score of parental supervision increased. Adolescents under greater supervision showed greater use of condoms in the first and last sexual intercourse, greater use of contraceptive methods and fewer sexual partners. These results suggest that the presence of parents in the lives of adolescents can provide conditions for sharing information, advice and positive skills with adolescents 9 , representing an opportunity to address issues related to sexuality. It is added that this finding corroborates international studies 2,6-8 and points out the role of parental educational practices that offer monitoring and application of rules at the same time they practice understanding and proximity attitudes as protection against the involvement of adolescents in behaviors that may pose a risk to sexual health, making them less susceptible to sexually transmitted infections (STIs) and pregnancy-outcomes that are increasing in our country among adolescents [23][24][25][26] .
Regarding STIs, a significant increase in the number of cases is reported 23,26 . In addition to these rates having increased in the last decade, another factor of great concern is the reduction in knowledge about the serological status in relation to the human immunodeficiency virus (HIV) and other STIs, especially among people aged 14 to 25 23 . These data, in view of our findings, make us reflect on the constant need for health actions aimed at preventing STIs.
Another important outcome in this scenario is teenage pregnancy, which can lead to consequences mainly in the lives of women, such as interruption of studies 16 . This, in turn, has a long-term impact on opportunities to complete education and enter the labor market, contributing to situations of greater vulnerability for these women and their children and for the perpetuation of the cycle of poverty and social exclusion 27 . In addition, teenage pregnancy reinforces gender inequalities. Including male adolescents in actions to reduce pregnancy is challenging, especially when considering the need to promote reflections on masculinity, virility, inequality and gender violence 27 . In this sense, the results of the study show that including the family in health actions, in order to strengthen the bond between parents and children, can be a promising strategy to reduce sexual risky behaviors among adolescents.
An American longitudinal study also reported that the proximity, monitoring and communication of parents during adolescence brought positive repercussions on the sexual health of their children, in addition to an impact on subsequent sexual behavior, after the teenage years 28 . It should also be noted that parental supervision was proven protective against other risky behaviors among adolescents, such as consumption of alcohol 29 , use of tobacco and drugs 30 , sedentary lifestyle and physical inactivity 31 . These findings reinforce the importance of the bond between parents and children, in the sense that familial practices such as supervision and parental presence can protect adolescents from negative health outcomes.
Other factors are known to also contribute to the sexual and reproductive behavior of adolescents, namely: schooling, use of licit and illicit drugs, peer influence, religion, dating relationships, access to health and education services, among others 8,32 . It should be added that, in addition to the family, the school and health services must play a strategic role in the training and education of children and adolescents, and must be understood as a central factor in the network for promoting the health of children and young people 2,3 . For this, intersectoral initiatives between education and health, such as the Health at School Program (PSE in the Brazilian acronym), are essential for a comprehensive health care for students. In this context, the professional nurse assumes the role by outlining effective actions for the adolescent public in order to build knowledge and start discussions, being able to contribute to better health practices together with parents and schools, to strengthen the bond and reduce risk behaviors among these young people 33 .
These programs and policies are essential to advance in the field of adolescent sexual and reproductive health, which was until recently a priority of primary care in the country 34 . Thus, this research is believed to contribute to the construction of the theme, in view of the uncertain scenario of public policies in this matter in the country, since some setbacks have been observed. Among them, the following stand out: our country's failure to sign the commitment of our country with the World Health Organization (WHO) regarding sexual and reproductive health of populations 35 ; the withdrawal of the adolescents' booklets from circulation, especially addressing information related to sex education and safe sex 36 ; the encouragement of sexual abstinence policies, which have already been considered ineffective 37 ; budget cuts 18 ; and several other setbacks previously described, which can support the argument of a possible programmatic emptying of sexual and reproductive health in the country 17 .
This study has some limitations, such as the inclusion of only adolescents who attended school, since data from the IBGE 38 indicate that 15.0% of adolescents aged 15 to 17 years were out of school in 2015. Another limitation is that it uses a parental monitoring proxy measure, not being able to address all aspects related to parental supervision. The different chances of sexual initiation at different ages are also a limit to be considered, which was corrected by adjusting the estimates for this variable.
It is important to highlight that the score added supervision of different natures, such limits/responsibilities and dialogue and affection. However, we found a relation that suggests dose-response: the greater the supervision, the lesser the behaviors considered risky, which may mean that both elements are important in parental supervision. Even with the release of the PeNSE 2019 macro data, the difficulty in accessing the databases of this research on the health of adolescents in Brazil prevents the most up-to-date assessment of these indicators and this relationship over time. Finally, the pandemic is believed to have caused major changes in parental supervision and adolescent sexual and reproductive health, which requires further investigation.
Despite these limitations, as it is a nationally representative survey that interviewed more than 100 thousand adolescents, the findings of this study are of great relevance for the country, since few studies have comprehensively investigated parental supervision and adolescent sexual behavior.
This investigation showed that adolescents who are under greater supervision by their parents have more responsible sexual behaviors, even though gender inequalities regarding parental supervision have been observed. The results show the fundamental role of the family in providing adolescents with conditions that stimulate healthy and risk-free sexual behavior through monitoring along with dialogue and affection.